Pharmacy Orders Pharmacy Name *Person Placing Order *Your Email *What kind of order are you needing ? *Pharmacy OrderQuote OnlySelect Compounding ProductsTopical pain reliefSuspensionsCapsulesOthersList of ingredientsSelect Ingredients *Please select an optionDiclofenacCyclobenzaprineLidocaineGabapentineMentholAmitryptilineBaclofenPercentage % *List of ingredientsIngredientStrengthChoose your BaseVersaproPLOVaselineLipobaseGlaxalbaseVersapro AnhydrouosAny other baseFinal Quantity in GM *Final Quantity in ML *Other Compounds Not Listed Above/Any Other InstructionsEmail Consent *I agree to receive emails from IDA Capilano PharmacySubmit Request To our pharmacy colleagues: Please submit your order using the above form . If you don’t yet have a Compounding Agreement with our pharmacy, please contact us at 780-784-5454, and we will assist you in setting one up. Community Compounding Agreement Compound Order Form